Racism As a Public Health Crisis

On March 29, Brandon Elliot walked up to a 65-year-old Filipino American woman near Times Square and kicked her in the chest.

Footage from the security camera of a nearby luxury apartment building recorded the attack: Elliot shoved her to the ground, and then repeatedly kicked and stomped on her, while shouting, “You don’t belong here!”

For me, the most chilling part of the video was not the actual attack. It was the moments afterward. A delivery person who witnessed the attack alerted two members of the building staff. Rather than racing out, the staff’s first reaction was to move toward the entrance and shut the door.¹

My mom lives about 10 blocks north of where the attack occurred. On a different day, that could have been my mother on her way to church being kicked in the chest as onlookers looked on and quietly shut the door.

I can’t tell you how disconcerting it is to watch one of the growing number of recordings of racial violence and see a victim who looks passably like a relative. Like a deep-fake video, your mind replaces the victim’s face with an image of your loved one. It’s the reason many have refused to watch the video taken by 18-year-old Darnella Frazier, who recorded George Floyd’s last breaths. Ms. Frazier herself noted, “When I look at George Floyd, I look at my dad. I look at my brothers. I look at my cousins, my uncles.”²

It took me a while to recognize the slow-burn reaction I was having to the viral clip. My colleagues, like your colleagues, largely fall into two types—those who volunteer to help out when there is need and those who wait for others to volunteer. Recently, this has been called the Shopping Cart Theory: Some people do the right thing—like putting away a shopping cart—even when they don’t stand to benefit, while others do not.³

Of late, my tolerance for the latter group has dropped precipitously. For example, when one of my fellows complained that he should not have to help a colleague, his argument did not receive the sympathetic hearing he was likely expecting. Despite my outward cynicism, I’ve always believed that in times of crisis, people will step up and do the right thing. Now, I’m not so sure.

This question is relevant to the Asian American and Pacific Islander (AAPI) community because violence against Asians is on the rise. The Stop AAPI Hate coalition notes that nearly 3,800 anti-Asian hate incidents occurred in the U.S. from March 2020 to February 2021.⁴ This likely represents only a fraction of the racially motivated attacks that actually occur.

Prosecutors are reluctant to classify many attacks as hate crimes because it can be difficult to prove intent, even when, for example, someone drives 30 minutes out of his way to kill women who work in Asian-owned businesses.⁵

During the pandemic, a 150% increase in anti-Asian American hate crimes has occurred.⁶ A recent Survey Monkey/AAPI Data Survey revealed the following:⁷

• 31% of Asian Americans often worry about being the victims of hate crimes;
• 12% of Asian Americans have been the victim of a hate crime or incident this year; and
• Only 30% would feel comfortable reporting a hate crime to law enforcement.

Racism & Me

One of my friends implied that, as a product of an upper middle class family and good schools, I was obviously not held back by my race. Here’s what she didn’t know: On the playground, kids used to approach me with their hands tugging at the sides of their face to narrow their eyes into slits, with the casual cruelty of children. As I grew older, the stereotypes became more positive. One of my classmates exclaimed that I was smart because I was Chinese, which I’m sure would have come as a shock to my Korean parents.

These experiences are such a cliché, you may not be surprised to hear that they were part of my life as well, having been raised in a predominantly white neighborhood.

You may be more surprised to learn it never really stopped.

In my second year of medical school, the dean of admissions was overheard saying we have enough of them, while gesturing at a list of Asian candidates. In my third year of medical school, I was stopped by the guard at the student housing complex where I had lived for years. I was carrying home dinner, and he assumed that I was delivering takeout for the local Chinese restaurant. As an intern, some of my patients complimented me on my English and asked me where I was really from. As a resident, my attending—himself a white immigrant to the U.S.—asked me how to say medium starch in Korean. As a junior attending myself, I listened to my intern as he detailed to an imaginary audience all of the physical features—and they were legion—the staff could use to differentiate him from the two other male Asian interns with whom he was routinely confused.

More recently, I had an admittedly ill-conceived conversation with a patient about immigration policy. I mentioned that some wanted to deport people who looked like me. She faced me squarely and asked, “Well, are you here legally?”

My friend has never heard me tell these stories. I rarely do. If you are a minority, then you have your own stories. Korean-American novelist R.O. Kwon, for example, tells the story of how she broached the subject of anti-Asian violence with her mother.⁸ Naturally, her mother turned this into an opportunity to counsel her daughter on being more careful with her own safety. Her advice? Don’t leave your house. “But if you do leave your house,” she added, “speak very loudly, so they know you belong,” as if perfect pronunciation were a shibboleth that would keep her safe.

Through tears, Ms. Kwon tells the rest of her story: “In that statement, there is an admission that my mother knows that she is less safe, because her English is accented.”

NPR reporter Asma Khalid has her own story to tell. She recently took to Twitter to mention that her dad was stopped by a new police officer, who told him, “You don’t look like an American.” He has lived in Indiana for 40 years.⁹ My dad has lived in New York for 50 years; I can easily imagine someone making the same comment to him.

The Price We Pay

I have spent the last few years watching in awe as increasing numbers of young people have taken up the cause of racial violence and demanded change, determined to move mountains with the force of their collective will.

For AAPIs in my generation, however, outrage gives way to exhaustion.

The comedian Hasan Minhaj, who was born in California of Muslim Indian parents, captures the generational difference eloquently. He relates a story of vandals who threw a brick through the window of his dad’s car, following a threatening phone call.¹⁰ His father, Najme Minhaj, responded by calmly picking up a broom and sweeping up the shattered glass.

The son was outraged and demanded to know how the father could not feel outrage as well. The father replied, “These things happen, and these things will continue to happen. This is the price we pay for being here.”

Hasan Minaj calls it the American Dream Tax: You endure some racism, and if it doesn’t cost you your life, you pay it.

Asians may be targeted, in part, because we are unlikely to complain about anti-AAPI violence. We smile, we shrug our shoulders, and we sweep up the broken glass. This reticence may be due, in part, to the following:

• Language barriers: Non-native Asian Americans who are fluent in English may still struggle with idioms or have a non-native accent that may not receive the warmest welcome; and
• Distrust of government: Many Asian immigrants come from countries where the government—and law enforcement—is best avoided. This leads to a reluctance to report crimes, even when they are the victims.

This sinister silence, however, minimizes the true impact of these events. By refusing to write ourselves into the narrative, we perpetuate stereotypes that make it easier to single out AAPIs for the violence that has become more commonplace.

Beyond Outrage

This issue is relevant to the AAPI community, but how is it relevant to us, as clinicians and health professionals?

At first, I didn’t think it was. But then I listened to Rochelle.

Racial & ethnic minorities have been disproportionately affected by COVID-19. Asian Americans are 53% more likely to die of COVID-19 than white Americans. … Native Americans & Alaskan Natives are 26% more likely to die; Hispanic Americans are 16% more likely to die. These differences cannot be explained by genetics alone.

Rochelle P. Walensky, MD, MPH, was a senior resident in my program when I was an intern. Many of you know her better as the director of the Centers for Disease Control and Prevention. On Apr. 8, 2021, she released a statement declaring that racism is a health threat:¹¹

What we know is this: Racism is a serious public health threat that directly affects the well-being of Americans. As a result, it affects the health of our entire nation. Racism is not just the discrimination against one group based on the color of their skin or their race or ethnicity, but the structural barriers that impact racial and ethnic groups differently to influence where a person lives, where they work, where their children play, and where they worship and gather in community. These social determinants of health have lifelong negative effects on the mental and physical health of individuals in communities of color.

Racial and ethnic minorities have been disproportionately affected by COVID-19. Asian Americans are 53% more likely to die of COVID-19 than white Americans, even after controlling for age and sex. Black Americans are 37% more likely to die; Native Americans and Alaskan Natives are 26% more likely to die; Hispanic Americans are 16% more likely to die.¹² These differences cannot be explained by genetics alone.

After I heard Dr. Walensky speak, I started to look around. In the U.S., Asians represent 17.1% of all physicians, 8.3% of all nurses, 15.3% of all physical therapists, 22.7% of all pharmacists, 5.3% of all healthcare administrators, and 33.7% of all rheumatology fellows. We are you. Our problems are your problems. And we are hurting.

So what can you do? First, don’t be outraged. Outrage is a cheap thrill. If you are truly outraged, then act on that emotion.

You can demonstrate your support for the AAPI community through a range of actions, from patronizing Asian-owned businesses to offering to escort an Asian friend who fears for her safety. I know Asian women who refuse to take public transportation because they are afraid of literally being thrown on the tracks. I wish I could say this is a ridiculous concern, but after watching report after report of Asians—particularly women and the elderly—being targeted on public transportation, it’s impossible to dismiss this concern as merely theoretical.¹³

Also, if you see something, say something. A witness or a bystander may be more comfortable reporting a hate crime than the actual victim.

Finally—and this may be hardest of all—I’ll ask you to give up the language that makes it easy to identify Asians as other. A kerfuffle in Congress arose over a decision to stop publishing some Dr. Seuss books that used racist imagery, including the depiction of Asians as yellow-skinned, coolie-hat-wearing, smiling folk.¹⁴ Although some bemoan the loss of these books to political correctness, the Dr. Seuss illustrations, The Simpsons’ character Apu, the toma­hawk chop, Aunt Jemima and Uncle Ben are all examples of language and images that may seem harmless, but actually perpetuate stereotypes that make it easier for minorities to be targeted.

Seeing Asian Americans as different from other Americans made it easier for President Franklin D. Roosevelt to issue Executive Order 9066 at the start of World War II.¹⁵ This executive order was used to strip almost 80,000 Japanese American citizens of their rights and their lands. These were people who were born in the U.S. People like me.

Along with 30,000 Japanese who had immigrated to the U.S., these 80,000 American citizens were forcibly incarcerated in detention camps. These American citizens and residents were deemed a security threat based on their race alone.

For those of you who believe this is ancient history attributable to the fog of war, I would mention that the U.S. Supreme Court decision that supported the internment of Asian Americans, Korematsu v. United States, has been rebuked but not overturned.¹⁶ In the past, I assumed that if a Korematsu-like case came before the Supreme Court, the outcome would be assured. Now, I’m not so sure.

For those of who do not face these issues on a regular basis, I realize this may be a lot to absorb. So I will leave you with one last piece of advice. The chief residents at my institution came up with a motto when they realized their interns were paralyzed by complexity: Don’t just watch the patient be sick. Do something. If it doesn’t work, do something else. But at least try.

Don’t just shut the door.

Philip Seo, MD, MHS, is an associate professor of medicine at the Johns Hopkins University School of Medicine, Baltimore. He is director of both the Johns Hopkins Vasculitis Center and the Johns Hopkins Rheumatology Fellowship Program.

Author’s Note

I would like to thank Myma Albayda, MD, Elizabeth Jones, Amanda Klekowski von Koppenfels, PhD, Julie Paik, MD, MHS, Ethan Craig, MD, MHS, and Anisha B. Dua, MD, MPH, for their helpful comments.

References

1. Bromwich JE. Doormen who stood by after brutal attack on Asian woman are fired. The New York Times. 2021 Apr 6.
2. Yancey-Bragg N. Darnella Frazier, the teenager who recorded George Floyd’s death on video, says it changed her life. USA Today. 2021 Mar 30.
3. Bolaños D. The curious case of the shopping cart theory. Medium. 2020 Jun 17.
4. Jeung R, Yellow Horse A, Popovic T, Lim R. Stop AAPI Hate national report. 2021.
5. Fausset R, Bogel-Burroughs, Fazio M. 8 dead in Atlanta spa shootings, with fears of anti-Asian bias. The New York Times. 2021 Mar 26.
6. Yeung D, Nguyen P, Shih RA. Asian American lives and livelihoods don’t just deserve our qualified support. The RAND Blog. 2021 Mar 22.
7. Pinkus E. AAPI data/SurveyMonkey poll: 2021 American experiences with discrimination. SurveyMonkey.com. 2021 Mar.
8. Yan J, Warner G. ‘We already belong’: A conversation with R.O. Kwon. KQED. NPR. 2021 Mar 26.
9. Khalid A. Twitter.com. 2021 Apr 9.
10. Hasan Minhaj: Homecoming king (TV special). Amazon Prime. 2017.
11. Wamsley L. CDC director declares racism a ‘serious public health threat.’ KQED. NPR. 2021 Apr 8.
12. Keating D, Cha AE, Florit G. ‘I just pray God will help me’: Racial, ethnic minorities reel from higher COVID-19 death rates. The Washington Post. 2020 Nov 20.
13. Moore T. Racist spews ethnic slurs, punches Asian woman in NYC subway station. New York Post. 2021 Mar 28.
14. Associated Press. Six Dr. Seuss books will be discontinued because of racist and insensitive imagery. CNBC. 2021 Mar 2.
15. Executive order 9066: Resulting in the relocation of Japanese (1942). OurDocuments.gov.
16. Bomboy S. Did the Supreme Court just overrule the Korematsu decision? Constitution Daily. 2018 Jun 26.